A&G Clinical Specialist

Healthfirst

. Manage clinical case development and case resolution for Appeals & Grievances cases .

Posted 11/10/2026full-timeRemote • United StatesMid-LevelSenior💰 $73,400 - $108,160 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing clinical case development and resolution for Appeals & Grievances, ensuring compliance with Federal and State regulations while effectively handling large caseloads in a fast-paced environment. Proficient in utilizing care management systems and Microsoft Office tools to prepare comprehensive case documentation.

Highest-signal resume keywords

RN OR LPNClinical Practice ExperienceUtilization Review GuidelinesCare Management SystemsCase Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Case DevelopmentCase ResolutionClaims ProcessingUtilization ReviewRegulatory ComplianceFile DocumentationInvestigative ResearchCritical Case Decision MakingProductivity ManagementQuality Expectations

Soft Skills

Effective CommunicationIndependent WorkTime ManagementAdaptabilityCollaboration

Tools & Technologies

Microsoft WordMicrosoft ExcelCorporate EmailMacessCCMSTruCareHyland

Certifications & Qualifications

Registered NurseLicensed Practical Nurse

Industry Keywords

Appeals & GrievancesDepartment of HealthFederal RegulationsState RegulationsHealth Plan PoliciesMedical Director ReviewMaximus Federal ServicesFair HearingExternal AppealUtilization Management

About the role

Key responsibilities & impact

Manage clinical case development and case resolution for Appeals & Grievances cases
Ensure compliance with Federal and/or State regulations
Independently investigate and resolve member- or provider-initiated cases
Manage Department of Health and executive complaints as needed
Handle clinical claim appeals from participating and non-participating providers
Research issues and reference internal health plan policies and procedures
Interpret regulations and make critical case decisions
Update file documentation, including file notes and case summaries
Manage duties within regulatory timeframes
Communicate effectively to hand off and pick up work from colleagues
Work within productivity and quality expectations
Prepare cases for Medical Director Review with complete investigative information
Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all appeal levels
Perform additional duties as assigned

Requirements

What you’ll need

RN or LPN
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), Milliman or Medicare local coverage guidelines
Ability to work independently on Microsoft Word and Excel, corporate email, and virtual filing systems such as Macess
Experience with care management systems such as CCMS, TruCare and Hyland
Demonstrated ability to manage large caseloads and work effectively in a fast-paced environment
Ability to work a Wednesday-Saturday, Thursday-Sunday, Friday-Monday, Sunday-Wednesday, Tuesday-Saturday, Wednesday-Sunday, or Sunday-Thursday schedule depending on selected shift
Work from home in one of the approved remote locations

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Competitive compensation and benefits package